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Antimicrobial stewardship (AMS), as one of the global strategies to promote responsible use of antimicrobials to prevent antimicrobial resistance (AMR), remains poor in many low-and middle-income countries (LMICs). We implemented a project aimed at strengthening AMS in Wakiso district, Uganda using a One Health approach. A total of 86 health practitioners (HPs), including animal health workers, and 227 community health workers (CHWs) participated in training workshops, and over 300 pupils from primary schools were sensitized on AMR, AMS, and infection prevention and control (IPC). We further established two multidisciplinary online communities of practice (CoPs) for health professionals and students, with a current membership of 321 and 162, respectively. In addition, a Medicine and Therapeutics Committee (MTC) was set up at Entebbe Regional Referral Hospital. The project evaluation, conducted three months after training, revealed that the majority of the HPs (92.2%) and CHWs (90.3%) reported enhanced practices, including improved hand washing (57.3% and 81.0%, respectively). In addition, 51.5% of the HPs reported a reduction in the quantity of unnecessary antibiotics given per patient. This project demonstrates that AMS interventions using a One Health approach can promote understanding of the prudent use of antimicrobials and improve practices at health facilities and in communities.
The 15-month project, as part of the CwPAMS scheme, was implemented in Wakiso district, central Uganda. Wakiso district has a total surface area of 2807.75 square kilometers, and a population of 2,007,700 people at an estimated growth rate of 4.1% [14]. ERRH, located in Entebbe municipality, Wakiso district, is the health facility where the main project interventions were implemented. ERRH has a 200-bed capacity, serving approximately 300 to 400 out-patients per day. Services offered at the hospital include but are not limited to: dental, pharmacy, peadiatrics, radiology, laboratory, maternity, maternal and child health, general surgery, internal medicine, and orthopedics. The hospital is led by a medical director, and approximately 10% of its staff are prescribers, including medical officers, dental surgeons, and clinical officers. ERRH serves a population of over 300,000, including the community in Entebbe municipality and neighboring areas, some being islands on Lake Victoria [14]. The community component of the project was implemented in Busiro South Health Sub District (HSD) in Wakiso district, which is comprised of three town councils (Kajjansi, Kasanje, and Katabi) and one sub county (Bussi). The HSD has a population of approximately 243,420 people. With a high number of households in Busiro South and the wider Wakiso district engaged in poultry and livestock farming, antimicrobials are used extensively [15,16]. The animal health workers involved in the project worked in Entebbe municipality either with the local government or as private practitioners. These health workers carry out diagnosis and treatment of animals mainly in the community. The CHWs in Busiro South HSD involved in the project not only treat childhood illnesses of diarrhoea, pneumonia, and malaria but also participate in educating the community on key public health issues, including AMR. This project was delivered as part of a 10-year international partnership between NTU, UK, and School of Public Health at Mak, Uganda. The partnership co-opted a multidisciplinary team for delivery of the project. This was essential due to the nature of the multifactorial challenges of AMR in humans, animals, and the environment. From the UK, specialist antimicrobial pharmacists and a medical microbiologist from BHT, a microbiology lecturer from School of Science and Technology, and an animal specialist from the School of Animal, Rural and Environmental Studies (ARES) at NTU took part in the interventions. In Uganda, project partners included: public health specialists, pharmacists including a clinical pharmacist, a veterinary doctor, and a microbiologist from Mak with support from health professionals from the Ministry of Health (MOH), ERRH, Wakiso district local government, and Entebbe Municipal Council. As part of the project, reciprocal visits between members from the UK and Uganda for planning, scoping, implementation, knowledge exchange, and sharing of best practices were held. The multidisciplinary project team conducted several meetings both physically and virtually before, during, and after implementation. The virtual meetings were held monthly using Skype and were attended by partners from both the UK and Uganda. The meetings facilitated project planning, implementation, monitoring, and evaluation as well as keeping track of the achievement of set goals. Other day-to-day communication to support implementation and timely completion of project tasks was achieved using a WhatsApp group. A google drive account was also set up for the team to access project documentation, such as previous meeting minutes, photos, and training materials. These communication avenues were invaluable for tracking progress of ongoing project activities and enhancing team work. Before and during project implementation, the project team held several meetings and engagements with various stakeholders in Uganda to ensure ownership, buy-in, and participation in planned activities. These stakeholders included government ministries (MOH and Ministry of Agriculture, Animal Industry and Fisheries—MAAIF), governmental parastatals (such as the National Drug Authority), professional associations (the Pharmaceutical Society of Uganda), training institutions (Mak), local governments (Wakiso district), health facilities (ERRH and lower level health facilities, such as health centre IIs, IIIs and IVs), local leaders (such as local council chairpersons), and the general community. The project team specifically engaged the MOH Technical Working Committee (TWC) on AMS, optimal access, and use, which is mandated to provide technical oversight of all AMS activities in the country. This engagement involved collaborative planning as well as regularly providing project updates in the TWC meetings and getting feedback that informed ongoing activities. The project held training workshops for HPs from both human and animal health to create awareness on AMR/AMS/IPC using a One Health approach. The workshops targeted selected HPs from government health facilities, including ERRH, as well as animal health workers in Wakiso district. The selection of HPs involved in the workshops was done in consultation with contacts at ERRH, Entebbe Municipal Council, and Wakiso District Health Office. Using the ‘training of trainers’ model, selected trained HPs were involved in training workshops for CHWs in AMR/AMS/IPC also using a One Health approach. The CHWs were from Kajjansi town council in Wakiso district where earlier NTU–Mak partnership interventions had been implemented [17]. All CHWs in the town council available at the time were involved in the workshops. In addition to the training of HPs and CHWs, the project also sensitised pupils in two primary schools in Wakiso district (St. Theresa and Kawotto Saviours Primary Schools) on AMR/AMS/IPC. St. Theresa’s is a government school in Entebbe municipality while Kawotto Saviours is a private school in Kajjansi town council, both in Wakiso district. These schools were selected in consultation with key stakeholders in Wakiso district. The project set up two online CoPs involving individuals from human health, animal health, and the environment. The first CoP was for health professionals, including HPs, researchers, policy makers, and academics, while the second targeted undergraduate students of Mak from various disciplines, including environmental health, veterinary medicine, pharmacy, biomedical sciences, social sciences, and computer sciences. In addition to the CoPs, multidisciplinary students at Mak and microbiology students at NTU were involved in various activities to promote AMR/AMS/IPC, including seminars, webinars, and competitions. The competitions, which were to design AMS messages using innovative approaches, were held to commemorate WAAW 2019. The winners of the competition were recognized as a form of motivation to continue being antibiotic guardians in their respective settings. Working closely with the hospital pharmacist, the project supported the establishment of a MTC at ERRH. This included appointing a multi-disciplinary team, in accordance with the MOH MTC manual [18]. The aim of the MTC is to support the safe and effective use of medicines through evaluation of usage, and to develop guidelines and protocols for medicine prescription and administration, as well as other health commodity related activities at the hospital. The MTC at ERRH has 12 members and three sub-committees reflecting the main functions: supply chain; pharmacovigilance, and AMS. During the course of the project, the MTC held three meetings to elect members, establish roles and responsibilities, develop work plans including a procurement plan for the 2020/21 financial year, and define standard IPC practices at the hospital. The MTC was specifically involved in: selection of medicines to be used; monitoring and ensuring rational use of medicines as per the standard treatment guidelines; development of draft treatment protocols; as well as developing Standard Operating Procedures (SOPs) during the management of COVID-19 patients. The final project evaluation involved assessment of practices of the beneficiary HPs and CHWs, which was carried out three months after their respective training workshop. Specifically, the evaluation was aimed at establishing any changes in practices of the HPs and CHWs related to AMR/AMS/IPC following the workshops conducted as part of the project. The practices assessed among the HPs included: increased use of the Uganda Clinical Guidelines (UCG) when prescribing antimicrobials; increased diagnosis based on laboratory results; improved handwashing; and more patient guidance and counselling when they do not require antimicrobials. For the CHWs, practices, such as improved hand washing with soap as well as increased community sensitization on avoiding self-medication, consulting animal health professionals whenever animals were ill, and avoiding the use of human prescribed medicines in animals including poultry, were assessed. The evaluation among the HPs used a self-administered questionnaire while for the CHWs, a researcher-administered questionnaire was used. In addition, key informant interviews using telephone were held with selected key individuals from the various stakeholders involved in the project. The interviews included HPs and CHWs who participated in the workshops, particularly those with leadership roles, CoP members, Wakiso district health office staff, and facilitators of the training. In this paper, we present a summary of the key findings from the evaluation. The diagrammatic summary of the project implementation is shown in Figure 1. Summary of the project implementation.
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